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DFW Report 2009-09-17

On Scene Report Sponsored by the Association of the United States Army

Coping with Unseen Injuries: From Battlefield to Homefront

A report on Defense Forum Washington 2009

By Stefanie Zehnder

In an effort to increase understanding of unseen injuries of war – and to connect wounded warriors and those who care for them with help they need as they deal with them – the U. S. Naval Institute and the Military Officers Association of America hosted their third annual Defense Forum Washington conference September 16 in Alexandria, Virginia.

The daylong forum, titled "Coping with Unseen Injuries: From Battlefield to Homefront," brought together nearly 600 combat veterans, family members, and those in and out of government working to assist the transition of men and women dealing with Post Traumatic Stress (PTS) and Traumatic Brain Injury (TBI). They heard a collection of powerful and passionate speakers, and participated in a forum posing tough questions.

The overwhelming consensus was that – although there are many programs to aid service members and their caregivers – much needs to be done to make those programs accessible. A significant part of the solution, too, will involve abolishing stigmas that cause such injuries to be dealt with differently than more obvious physical wounds.

"The focus on (unseen injuries) is absolutely critical, the challenges we have are just now beginning to be understood," Admiral Michael G. Mullen, chairman of the Joint Chiefs of Staff told DFW attendees.

"This is different from a car crash, this is different from a football injury, and this is different from being a boxer," Mullen said. "These are 20-somethings who are wounded, who have 50, 60, 70 years to live, and that's where the sustained effort has got to come in."

"I swore that I would do all I could to avoid generating another generation of homeless veterans as we did in Vietnam. Shame on us if we don't figure that out."

Mullen promised progress on a governmental response to wounded warrior care – to include better coordination between the Defense Department (DoD), Department of Veterans Affairs (VA) and other agencies. But he noted that a major part of the solution is tapping into a sea of goodwill across the nation – non-profit groups looking for ways to help individual wounded warriors in their areas. Admiral Mullen introduced a special assistant he has appointed to figure out ways to expand care in this way. The challenge, he said, is matching a need to a donor who wants to make a difference. Part of the answer will involve broad community involvement through such social media as Twitter and Facebook, establishing a clearinghouse, and through universities.

"These are America's citizens who are going off doing our country's bidding" Mullen said of America's armed forces. When they are hurt as they do so, he said, the Nation incurs a serious obligation. "This is a debt. As far as I'm concerned this needs to be the first check we write."

Retired Army Colonel Roger Dimsdale, drawing from his experience as a former Chief of Staff of the VA Wounded, Ill and Injured Senior Oversight Committee, moderated a panel on how military leaders can and should deal with potential ""unseen injuries"" before, during and after combat deployments. An important first step, panelists agreed, is breaking down the stigma against discussion of PTS and TBI.

Criminal involvement is not an uncommon side effect of PTS, said Brockton D. Hunter, a Minnesota attorney and former enlisted soldier. He said some veterans do not acknowledge suffering PTS effects until after interaction with the courts. Because of increasing awareness of the connection between PTS and criminal activity, he noted, there is a movement in the civilian criminal justice system that encourages treating rather than incarcerating veterans in such circumstances.

Whether initiated by leaders, families or fellow service members, panelists pointed out that the ability to start the conversation about unseen injuries is vital. "We try to set the environment for Marines and families," said Marine Colonel Andrew R. MacMannis, commanding officer of the Marine Corps' Training Command.

"Because it's personal, it's hard to get them to start talking about it, so what we try to do is set the environment beforehand – where if there's a problem, we talk about it," said MacMannis.

Although it is good for formal leaders to be involved, chaplains are instrumental for the initiation of communication, said Army Colonel Richard B. O'Connor, Logistics Division Chief of the Pakistan Afghanistan Coordination Cell. "Soldiers didn't feel comfortable walking up to the colonel and saying, 'Hey sir, I have an issue.'" Chaplains who spent their days alongside service members on the front lines, he said, were frequently the ones who brought serious ""unseen injuries"" to light.

For mental health experts working with active duty soldiers, the key is to "establish trust and make your presence available," said Dr. Kathy Platoni, Army Reserve Colonel and Clinical Psychology Consultant to the Chief, Medical Service Corps. "If you don't become one with them and get into the trenches, they'll never trust you. That's where we do our best work."

Accessing the huge number of resources available is difficult, said Colonel Platoni, and many families are uniformed.

Gregg Zoroya, a USA Today reporter whose writing has focused on the impact of war on those who wage it, moderated the event's second panel – on the "Implication of Unseen Injuries: How Do We Respond on the Homefront?"

"The initial question," noted Zoroya, "after all this time (the eight years of war since 9/11), is what are the programs that work that help the warriors come home and reconnect. How do you actually get them the help they need when they need it?"

Army Reserve Lieutenant Colonel David Rabb, director of psychological health for the 63rd Readiness Support Command at Moffett Field, California, is one of many trying to create synergy between DoD, the VA and local communities.

"Community heals and isolation kills," said Rabb.

He observed a twin challenge in providing help those injured while in service: finding the best services for each, then convincing wounded warriors and family members to ask for help.

While a great deal of national goodwill can be brought to bear to help injured veterans, one panelist noted, making such a system work will require helping civilian communities better understand military culture and the nature of combat.

"Our civilian community providers don't get us – they don't understand the military," said retired Navy Captain Catherine A. Wilson. "We've got to educate our providers," said Wilson, who serves as the Executive Director of the Virginia Wounded Warrior Program. The VA is not the only resource for veterans and their families, she said. Universities, faith based groups, and peer-to-peer groups are all eager to help, she affirmed; however, "the education piece is vital."

"We need to serve those who serve," said Barbara Van Dahlen, Founder and President of the non-profit organization "Give an Hour" which over recent years has provided military service members with 16,895 no-charge hours of mental health services, including direct counseling, education, and outreach. The gap between the civilian world and the military world is getting smaller, she said, but the larger public still requires much education in understanding the military so that service members can get help on an individual level from organizations in their communities.

A member of the audience challenged the panel to give a report next year to this forum on what individual states have specifically done for family members to provide group therapy, counseling, community employment and help in dealing with PTS and TBI. Wilson, among others, quickly accepted the questioner's challenge.

Commanding General of the Army Reserve Lieutenant General Jack Stultz presented DFW attendees with the event's luncheon keynote address. (Senator John McCain had been scheduled to speak, but extended sincere apologies to conferees when unexpected business on the Senate floor caused him to be unable to attend.) Having combined simultaneously distinguished careers at Proctor and Gamble and as a frequently deploying reservist, Stultz offered intimate knowledge of the needs of citizen soldiers and their families.

Stultz and his wife are experimenting with an idea to help reserve soldiers returning from war. The "Army Strong Community Center" in Rochester, New York, is part of a pilot program creating "virtual installations" supporting military people and their families – not near military installations, but in communities across the nation where soldiers, veterans and families live apart from traditional military information sources. "We've already had 650 family requests in Rochester." There is a need for families to have a user-friendly place to plug into and connect, he said.

Such centers, he said, will also be places for communities to plug into the military. Echoing a theme expressed by many throughout the day, he said noted that there is no shortage of local support for military families, but without an outlet much of that concern dissipates. In every community in America, said Stultz, you know where the local post office is; there need to be similar centers, he believes, at which veterans and the community can come together.

Stultz offered intimate observation on how, when soldiers return from war, it is frequently difficult to wind down to the apparent triviality of day-to-day peacetime.

"I've been at war for two years," he said, "high intensity and high responsibility. I've lost soldiers on the battlefield that I had to deal with. And I find myself back in a conference room at Proctor and Gamble talking about toilet paper," he said with laugh. The difficulty is "trying readjust to society when you hear someone whine about something that isn't important – you just want to explode," he said.

Echoing previous speakers, he said PTS is often experienced much later than the 90-day reintegration period often afforded returning warriors. "We don't start to see the symptoms until after 180 days or longer," he said. ""We ought to make counseling mandatory.""

The final panel of DFW 2009 focused on the needs of caregivers. Karen Guice, Executive Director of the Federal Recovery Coordination Program – an agency that combines efforts of the VA, DoD and others – estimated that 44 million Americans serve as informal caregivers. Those dealing with young wounded warriors, she said, face a need to understand injuries that are often very complex.

Eric W. Christensen, Managing Director of Health Research Policy at the Center for Naval Analyses, found that attending to seriously wounded and ill service members took a "substantial" economic toll on caregivers. Of those acting as caregivers of seriously wounded or ill service members, about three quarters gave up paying job before becoming a caregiver, he said. Seven out of eight had eventually to quit jobs to care for their wounded veteran.

Many reported financial challenges with their housing while being a caregiver, he added. Christensen's research also found that as individuals' care-giving burdens increase, so too do their financial burdens.

"In the course of our study one thing that became very apparent was the distinction in the support for those with TBI and PTSD and those with visible wounds" Christensen said. "Veterans with TBI still require a caregiver but because they do no meet the medical qualifications they do not always get that (formal, funded support.)"

"There needs to be an understanding for every family of a soldier with TBI – no matter how high functioning – that the care giving role never ceases," said Shannon Maxwell, wife of severely injured retired Marine Lieutenant Colonel Tim Maxwell. Through her experience of caring for her husband, she co-founded Hope For The Warriors, a non-profit organization committed to enhancing quality of life for veterans and families nationwide who have been adversely affected by injuries or death in the line of duty.

Maxwell stressed the need for caregivers to have "access to useful information on benefits." She was among a number of participants who stressed that it may be best to not provide a deluge of benefits information to families during their first, shocked weeks of dealing with a wounded loved one. A number of DFW participants noted that providing information over time, specifically as it is needed, would better serve the injured and their caregivers. Maxwell also noted that more could be done to adequately educate families as they faced the process associated with the retirement and separation from service of a wounded warrior.

Leslie Kammerdiener, mother of severely wounded Army Corporal Kevin Kammerdiener, expressed her deep disappointment and frustration with the lack of support she received from the Department of Veterans Affairs. She noted that the care her son received varied widely from the attentiveness at the Brooke Army Medical Center in Texas to what she characterized as disregard at VA poly-trauma center in Tampa, Florida.

"The system is very harsh for a lot of us," she said. "We did not have a good experience." Much of the frustration was caused by lack of information and support for the caregivers. As a mother of a wounded soldier, Kammerdiener does not receive any of her son's benefits and thus bears the brunt of the financial weight of caring for him.

Kammerdiener said the Federal Recovery Coordination Program representative assigned to her is "the one thing that keeps me going."

"I'm not going to sit here today and tell you what a good job we're doing taking care of our wounded warriors," said Noel Koch, Vietnam veteran and newly-appointed Deputy Under Secretary of Defense for Transition Policy and Care Coordination. "There are a number of things we do well. We do power point, we do storyboards, we do conferences, and we generate paper. The thing we don't do very well is seeing anything come out of this process."

"The fact is that you can feel like you're in good shape when you come home and fifteen years later you can be sitting there reading watching television and you can find yourself crying," he paused, "and I know something about that."

Today there are all sorts of resources and websites for service members and their families, he said. Two specifically noted as useful were those of the National Resource Directory and a nonprofit group called USA Together. He admitted, though, that a deluge of information, spread across disparate resources, can be defeating. The issue is how to easily access specifically required information. Another issue yet to be resolved, he noted, is the disparity of quality of post-injury – and even post-active duty – care among the branches of service.

Koch noted a need to change current military culture, in which services and service members have traditionally viewed discharge dates as an end of each group's involvement with the other. He suggested a need for both military services and individuals in uniform to think collectively about how to improve long-term education and employment of young veterans likely to live 60-65 years after their service.

The final DFW 2009 speaker is herself a wounded warrior. Now Assistant Secretary of Veterans Affairs for Public and Intergovernmental Affairs, L. Tammy Duckworth was seriously injured while fighting in Iraq. In 2004, during a mission north of Baghdad, a rocket-propelled grenade hit the Blackhawk helicopter she was co-piloting. As a result, Duckworth lost both of her legs and partial use of one arm. After her recovery, she has dedicated her life to advocating on the behalf of the disabled – particularly those with war wounds. Sworn in to her present post earlier this year, she had much to say about what she termed a new direction at the Department of Veterans Affairs.

Duckworth reiterated the "covenant America has with its veterans; our family members are there throughout our careers, they do this out of their love for the service members and for their nation." She said the VA is entering into a new era lead by retired Army Gen. Eric K. Shinseki.

"This new secretary will not accept poor behavior from the VA," she said and assured the audience that the new VA culture will be one of transparency, in which problems are self-reported. Secretary Shinseki's goal, said Duckworth, is to transform the VA into a people-centric, high-quality, forward-looking organization.

One way the VA hopes to do this is, she said, is by implementing a long-discussed electronic medical records system to track service members "from the day they enlist to the day they are laid to rest."

"With troops coming home from Iraq and Afghanistan and with Vietnam vets getting older, we find that more and more veterans are coming back to VA and we are going to see a boom at the end of this month," Duckworth said.

Duckworth acknowledged the legitimacy of issues raised regarding compensation of parents who serve as wounded warrior care givers, but said legislative change would be required to remedy the situation.

"We will not abandon our posts," said Duckworth, promising that when supporting initiatives to care for wounded warriors, "we will always be there for our fellow vets. It's our job to serve them."